"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

March 01, 2015

Gujarat has achieved the ignominious distinction of being the state with the highest number of swine flu deaths in the country since January 1.

On Saturday, with nine more patients succumbing to the deadly H1N1 virus, the state overtook Rajasthan in total number of deaths from the disease. Gujarat's toll stood at 265 while Rajasthan has recorded 261 deaths.

The total number of swine flu cases in the state has risen to 4,368 but the state government is yet to declare the outbreak of an epidemic.

Meanwhile, in a sudden change of weather, cold winds began blowing through the city on Saturday evening. The weather department has forecast light rains in Gujarat region on Monday and Tuesday. This will only fuel the spread of swine flu in the state, said health experts.

"There would be light rain in parts of Gujarat region on March 2. The weather will start clearing from March 3 onwards," said Jayanta Sarkar, director of IMD, Gujarat. Ahmedabad recorded maximum of 30.4 degree day temperature and 15.4 degree night temperature on Saturday.

On Saturday, Gujarat recorded 206 new cases and nine swine flu deaths. Ahmedabad led with 97 new swine cases and three deaths, followed by Surat which saw 26 new cases and one death. Vadodara saw 10 new swine flu cases, followed by eight new cases in Kutch, Rajkot and Bhavnagar. Gandhinagar, Patan, Sabarkantha recorded six cases each. Banaskantha, Mehsana, Anand, Aravali recorded four cases of swine flu each.

February 26, 2015

A west Indian city has banned large public gatherings in an attempt to halt the spread of swine flu, which has claimed at least 926 lives nationwide in 11 weeks.

Officials prohibited gatherings of five or more people in Ahmedabad, the capital of Gujarat state, starting Wednesday. Marriages and funerals are exempt from the ban, but participants will need to wear protective masks, officials said.

The law invoked for the ban is generally used to maintain law and order, not health, and officials said they would be flexible in interpreting which public events would be prohibited.

Gujarat has had the second-highest number of deaths, with 231, after the northwestern state of Rajasthan, where 234 have died.

Among the thousands in Gujarat testing positive for H1N1, the virus which causes swine flu, were its assembly speaker and state health minister.

Doctors said the death toll was high because many patients delayed going to hospitals.

The Health Ministry said most of the more than 16,000 cases reported nationwide since mid-December were in the states of Gujarat, Rajasthan, Maharashtra, Telangana and Madhya Pradesh.

In an increasingly connected world, rapid sequencing, combined with new ways to collect clinical and epidemiological data, could transform our response to outbreaks. But the power of these potentially massive data sets to combat epidemics will be realized only if the data are shared as widely and as quickly as possible. Currently, no good guidelines exist to ensure that this happens.

Speed is everything

Researchers working on outbreaks — from Ebola to West Nile virus — must agree on standards and practices that promote and reward cooperation. If these protocols are endorsed internationally, the global research community will be able to share crucial information immediately wherever and whenever an outbreak occurs.

The rapid dissemination of results during outbreaks is sporadic at best. In the case of influenza, an international consortium of researchers called GISAID established a framework for good practice in 2006. Largely thanks to this, during the 2009 H1N1 influenza outbreak, the US National Center for Biotechnology Information created a public repository that became a go-to place for the community to deposit and locate H1N1 sequence information4.

By contrast, the publishing of sequence information in the early stages of the 2012 Middle East respiratory syndrome (MERS) outbreak in Saudi Arabia highlighted uncertainties about intellectual-property rights, and the resulting disputes hampered subsequent access to samples.

Sharing data is especially important and especially difficult during an outbreak. Researchers are racing against the clock. Every outbreak can mobilize a different mixture of people — depending on the microbe and location involved — bringing together communities with different norms, in wildly different places. Uncertainties over whether the information belongs to local governments or data collectors present further barriers to sharing.

So, too, does the absence of patient consent, common for data collected in emergencies — especially given the vulnerability of patients and their families to stigmatization and exploitation during outbreaks. Ebola survivors, for instance, risk being shunned because of fears that they will infect others.

Fortunately, useful models for responsible data sharing have been developed by the broader genomics community. In 1996, at a summit held in Bermuda, the heads of the major labs involved in the Human Genome Project agreed to submit DNA sequence assemblies of 1,000 bases or more to GenBank within 24 hours of producing them5, 6. In exchange, the sequencing centres retained the right to be the first to publish findings based on their own complete data sets, by laying out their plans for analyses in 'marker' papers.

This rapid release of genomic data served the field well. New information on 30 disease genes, for instance, was published before the release of the complete human genome sequence. Since 1996, the Bermuda principles have been extended to other types of sequence data and to other fields that generate large data sets, such as metabolite research.

Guidelines for sharing

More-recent policies on data release similarly seek to align the interests of different parties, including funding agencies, data producers, data users and analysts, and scientific publishers. Since January, for example, the US National Institutes of Health has required grantees to make large-scale genomics data public by the time of publication at the latest, with earlier deadlines for some kinds of data7.

We urge those at the forefront of outbreak research to forge similar agreements, taking into account the unique circumstances of an outbreak.

February 24, 2015

Via CIDRAP: Flu Scan for Feb 24, 2015. Click through for the full report (which also discusses seasonal flu) and numerous links. Excerpt:

H7N9 sickens three more in China

Two of China's provinces—Anhui and Guangdong—reported a total of three new H7N9 avian influenza cases today, according to separate health department reports.

Anhui province reported two of the case-patients, a 48-year-old man from Ma'anshan and a 75-year-old man from Wuhu, according to a provincial report translated and posted by FluTrackers, an infectious disease news message board. Both are in critical condition and had been exposed to live poultry before they got sick.

The two infections are Anhui province's first H7N9 cases in the third wave of illnesses that started in October.

Guangdong province's patient is a 58-year-old man from Zhaoqing who is hospitalized in critical condition, according to FluTrackers' translation of an official provincial report.

The three new cases lift the global H7N9 total to 611, according to a case list maintained by FluTrackers.

Egypt confirms 5 new H5N1 cases

Egyptian authorities have confirmed five new cases of H5N1 avian flu, continuing an unusual flood of cases in recent weeks, according to a Ministry of Health and Population statement translated and posted today by FluTrackers.

The cases involve a 34-year-old man in Faiyum governorate, a 36-year-old man in Cairo governorate, a 38-year-old man and a 3-year-old girl from Asyut governorate, and a 27-year-old man from Minya governorate. The 34-year-old is being treated at a Faiyum hospital, while the other four patients have been treated and released, the health ministry said.

The statement said eight H5N1 patients remain hospitalized in the country. Egypt has now confirmed 69 cases this year, according to a list maintained by FluTrackers. In all of last year the country reported 30 H5N1 cases, according to World Health Organization (WHO) data. The previous high was in 2006, when Egypt had 55 WHO-confirmed cases.

February 22, 2015

CHENNAI: The state government may be sparing in the supply of anti-flu shots, but there are many who are making a killing of the public fear in the absence of a policy on vaccination.

Several corporate hospitals in the city are openly pushing for vaccination by putting up sign boards, even as the state government reserves the shots only for doctors and health workers. The vaccine, available in the form of injections and nasal spray, costs between 600 and 1,000.

Officials in the directorate of public health said they are aware that pharmacies and hospitals are profiting from the outbreak, but were helpless. "Panic has pushed several people to go for vaccination. We can't stop them from doing that. But, in most cases, the shots are unnecessary," said a senior DPH official. What goes unsaid in these hospitals is that the efficacy of the vaccine is only about 70%, and it takes about three weeks for the immunity to develop.

The state government, at present, is providing vaccines only to those handling H1N1 patients and distributing antiviral drug Tamiflu to those who have been in close contact with them.

Some private firms in the city are also holding vaccination camps for their employees and their families. Representatives of these companies say the shots are being given following request from their employees, especially those who travel frequently to states like Rajasthan, Gujarat and Mahrashtra, where the flu is endemic.

"We hold these camps as a precautionary measure," said a senior employee of tyre manufacturer Madras Rubber Factory (MRF), which will conduct a drive for its employees on Monday.

The Centers for Disease Control and Prevention, Atlanta, the leading public health institute in the US, recommends vaccine for children between 4 months and 5 years, those above 50 years old, people suffering from chronic respiratory and cardiovascular problems and diabetes, pregnant women and health workers.

However, with the state government failing to give any clear directive on vaccines, anxious parents and children are playing right into the hands of private hospitals and the pharma sector.

Vaccine expert Dr T Jacob John said the only way to tackle the issue of vaccines during such outbreak is to bring a national policy on vaccines for communicable diseases.

Meanwhile, the number of H1N1 positive cases touched 241 on Sunday with 11 more new cases being reported, including two from Chennai.

February 19, 2015

JAIPUR, India — Indian officials this week scrambled to cope with a rise in cases of the flu, which they say has sickened thousands of people and caused the deaths of 700 since the beginning of January.

The Health Ministry has deployed teams of experts to five regions where the largest numbers of cases have emerged, and asked state governments to study “patterns in mortality.”

According to the World Health Organization, India is reporting unusually high levels of H1N1 seasonal flu, a descendant of the swine flu that first emerged in Mexico in 2009. That new flu — actually a novel mix of human, bird and pig genes — spread widely enough to be declared a pandemic, but ultimately proved to be no more lethal than other flus. Health Minister J. P. Nadda told reporters on Thursday that “we should not panic, but at the same time, remain alert.”

India’s vast and densely packed population, coupled with an overburdened health care system, has led to fears of epidemics in the past. Though some scientists said the number of cases documented this year indicated nothing more than a bad flu season, news channels have still covered the outbreak breathlessly.

Aligarh Muslim University, in the northern state of Uttar Pradesh, suspended classes until Wednesday after one infected student died and eight students and faculty members tested positive for the virus. The National Law University in Jodhpur, where one student tested positive, has suspended classes until March 1.

A state-level task force assigned to examine the outbreak in the northern state of Rajasthan, where around 200 people have died, concluded that nearly three-quarters of the deaths occurred because patients received treatment for the flu too late, said Dr. Ashok Panagariya, the task force chairman; the remainder were already weakened by other illnesses, like cancer or diabetes.

So far, more than 11,000 people have tested positive, but it is unclear how many more people have been sickened; even in wealthier countries only a tiny fraction of people who get sick are ever tested.

Patients have converged on large government facilities like Sawai Man Singh Hospital in Jaipur. The hospital has 1,953 beds, according to officials, but accommodates an average of 3,000 patients every night. Scores of relatives camped outside its entrance on Wednesday, their mouths covered by handkerchiefs or scarves or cheap paper masks.

One group awaited news about Vishnu Kumar Prajapati, 30, a day laborer who was in the intensive care unit, breathing with the aid of a ventilator. When he fell ill the week before, they said, the doctor in their village, seven miles from Jaipur, did not test him for the H1N1 virus. Days passed before they checked him into a private clinic, which immediately sent him to the government hospital. By then, he was gasping for air, his lungs filling with fluid.

“We cannot say how he is,” said one relative, Prahlad Sahay Prajapati, 40. “He is covered with all kinds of machinery.”

Government scientists sequenced the virus to check for mutations, and found no changes from the original 2009 H1N1 virus, meaning that patients should respond to the antiviral drug Tamiflu.

“It’s the same virus, the same medication, but the ratio of mortality is higher,” said Dr. Ajeet Singh, a hospital administrator. “These people are taking treatment from the doctor at the village level,” among them homeopaths and other practitioners of traditional medicine, he said, “and that is the main reason.”

“The person is coming to us at a later stage,” Dr. Singh added.

H1N1 sickened and killed a lot of people in India back in 2009-10 as well, but since then no one's paid much attention to it except the Indians. Everyone else just ignores it as "seasonal flu," as if seasonal flu of any strain weren't a serious problem anyway.

The response to the emergence of the 2009 influenza A(H1N1) pandemic was the result of a decade of pandemic planning, largely centred on the threat of an avian influenza A(H5N1) pandemic. Based on a literature review, this study aims to define a set of new pandemic scenarios that could be used in case of a future influenza pandemic.

A total of 338 documents were identified using a searching strategy based on seven combinations of keywords. Eighty-three of these documents provided useful information on the 13 virus-related and health-system-related parameters initially considered for describing scenarios. Among these, four parameters were finally selected (clinical attack rate, case fatality rate, hospital admission rate, and intensive care admission rate) and four different levels of severity for each of them were set.

The definition of six most likely scenarios results from the combination of four different levels of severity of the four final parameters (256 possible scenarios). Although it has some limitations, this approach allows for more flexible scenarios and hence it is far from the classic scenarios structure used for pandemic plans until 2009.

They suggest resources would be better spent on arrival screening, which would reduce but not eliminate cases.

They said questionnaires are the most effective detection method when diseases are in their early stages and not exhibiting any symptoms.

But they found that, at best, just 25% of people honestly reported on exposure to flu during the 2009 swine flu pandemic, and some might even have hidden symptoms by taking medication. They said this is the first time available information has been used to arrive at an estimated figure.

Fever testing of passengers with diseases with long incubation periods such as Ebola and Marburg is particularly ineffective, they warned, but works better for diseases such as swine flu that take a shorter time to incubate.

Symptoms of some diseases will progress during transit so can be easier to detect on arrival, they pointed out.

The research carried out at the University of California, Los Angeles (UCLA), and the London School of Hygiene and Tropical Medicine will be published in the journal eLife.

February 11, 2015

In the West, few pay attention to H1N1 these days. Sure, it was pandemic flu in 2009-10, but now it's just a seasonal flu—if that. Not in India, which took a beating in 2009-10 and still takes H1N1 seriously. Via The Times of India:Health Ministry holds review meeting on H1N1.Excerpt:

NEW DELHI: The status of H1N1 influenza being reported from different states was reviewed by the Health Ministry at a high-level meeting held here on Wednesday.

Director General Health Services (DGHS) Dr Jagdish Prasad, representatives of leading government hospitals such as Dr. Ram Manohar Lohia Hospital, Safdarjung, AIIMS, and from Indian Council of Medical Research (ICMR) and National Center for Disease Control (NCDC) were present in the meeting that was chaired by Health and Family Welfare Secretary B.P. Sharma.

It was noted that that during the period from January 1 to February 10 this year, the total number of H1N1 cases is 5,157 and number of deaths is 407. Largely the cases are from Delhi, Gujarat, Rajasthan, Karnataka, Madhya Pradesh, Maharashtra, Tamil Nadu and Telangana whereas largely the deaths due to H1N1 are in Maharashtra, Madhya Pradesh, Gujarat, Rajasthan and Telangana.

The current trends of morbidity and mortality, the diagnostic and test algorithms being followed, availability of diagnostic kits and drugs, and other preventive measures were discussed.

Based on the advice given by experts, it was decided that various health institutions treating H1N1 cases be advised for vaccination against H1N1 influenza for the concerned health workers in the hospitals in contact with H1N1 patients. This will be in addition to the proper personal protective measures being followed at the hospitals.

Guidelines are being drafted for vaccination of healthcare workers and these will be shared with the states for dissemination to all health institutions.

The Government of India has already placed an order for enhancing stock of diagnostic kits to be supplied to the lab network under Integrated Disease Surveillance Programme (IDSP) being used for testing H1N1 influenza. To enhance the level of preparedness, additional 60,000 Oseltamivir medicines and 10,000 N-95 masks are being procured.

Check Google News's H1N1 page to see how extensively it's being covered in the Indian media.

February 03, 2015

Historically, most attempts at border screening have been ineffectual, as demonstrated by the pandemic spread of SARS and influenza A(H1N1)pdm09 to many countries despite the use of border screening.

Modeling and observational studies have indicated that border screening is likely to be unsuccessful in preventing or delaying the entry of such diseases into a country. Border screening generally has high opportunity costs, both financially and in terms of the use of scarce public health staff resources at a time of high need.

We conclude that border screening should not be used. Instead, the less costly measure of providing information to arriving travelers is recommended, together with effective communication with local clinicians and more effective disease control measures in the community.